Is it time to relax criteria for valve-sparing repair of tetralogy without increasing re-intervention rates in the intermediate term?
Omar Toubat, *Winfield J. Wells, *Vaughn A. Starnes, *Ram Kumar Subramanyan
Surgery, University of Southern California, Los Angeles, California, United States
Objective: There is an increasing trend towards valve-sparing repair (VSR) in anatomically suitable patients with tetralogy of Fallot (TOF). Of necessity, this can result in residual right ventricular outflow tract (RVOT) gradients. We sought to evaluate the natural history, progression and clinical implications of RVOT gradients following VSR of TOF.
Methods: We retrospectively reviewed the records of consecutive TOF patients who underwent VSR at our institution between 01/2010 and 06/2021. Patient demographic, clinical, and operative data were collected. RVOT gradient, pulmonary valve annulus (PVA) diameter and Boston z-scores, and tricuspid regurgitation (TR) velocity were recorded from serial postoperative transthoracic echocardiograms. Data are presented as median and interquartile range or number and percentage.
Results: A total of 156 infants (boys 92, 58%) underwent VSR at 6.5 (4.9-8.4) months of age and 6.6 kg (5.6-7.7) weight. PVA z-score at repair was -1.7 (-3.1- +0.4). There was 1 (0.6%) operative mortality. The remaining 155 patients were followed for 69.4 months (4-106.2). There were no mortalities during follow-up. Peak gradient across RVOT at discharge was 2.4m/s (1.9-2.9), with 37 (23%) patients having a gradient > 3m/s and 3 patients with gradient > 4m/s. 46 (30%) patients had a PVA z-score of -3 or smaller. RVOT gradients rose transiently over the first year after repair but stabilized thereafter (Fig 1). PVA Z-score was -1.9 (-3.4 to 0.5) at discharge and ‘grew’ slightly disproportionately for a z-score of -0.8 (-1.7 to 0.4) at last follow-up.TR jet remained stable at 2.4m/s (1.2 – 2.8 m/s). 11 (7%) patients required RVOT reintervention (6 percutaneous and 7 surgical) 12 (6-24) months following VSR. 5/6 (83%) percutaneous interventions occurred in the first year after repair. 4/7 (57%) required surgical reintervention on the RVOT – one re-resection of RVOT and 3 transannular patches at 18 (10.5-24) months after VSR. Only one of these patients had a discharge gradient over 3m/s. Three patients required pulmonary valve replacement at 1, 4 and 9 years after repair. Freedom from any RVOT re-intervention was 96%, 92% and 90% at 1, 5 and 10-year follow-up (Figure 2). Receiver operator characteristic curve did not identify an RVOT gradient or PVA z-score at discharge that correlated with re-intervention at follow-up.
Conclusions: In a contemporary series of VSR for TOF, RVOT outcome is durable during intermediate follow-up. RVOT gradient tends to increase early in follow-up but stabilizes over time. Given the favorable re-intervention profile even in patients with smaller PVA and higher RVOT gradient that traditional cut-offs, relaxing criteria for VSR of TOF should be strongly considered.
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